Ординатура / Офтальмология / Английские материалы / Clinical Ophthalmic Echography_Harrie_2008

QH was a 13-year-old child who presented to her pediatrician with complaints of eye pain. He did not appreciate any abnormalities of her eyes but there was mild swelling of the eyelids. An x-ray was obtained and was interpreted as normal. She was referred to an ophthalmologist for a consultation that day. The globes were normal, but A-scan revealed marked signals from both ethmoid sinuses consistent with sinusitis (Fig. 220). She was started on antibiotics and decongestants with resolution of her symptoms over several days.

Downward displacement of the globe is seen with lesions such as lacrimal gland tumors. Traditional teaching has been that 50% of lacrimal gland lesions are nonepithelial, such as lymphomas and inflammatory infiltrations. The other 50% are epithelial tumors, such as pleomorphic adenomas (benign mixed tumors) and adenocystic carcinomas. This concept has been challenged by Shields,38 who found that inflammatory and lymphoid lesions are two to three times mores common than epithelial tumors.

FIG. 220. A-scan of ethmoid sinus signals (vertical arrows)

The pleomorphic adenoma is the most common “benign” neoplasm of the lacrimal gland, although this lesion has malignant potential if it is not completely excised. These tumors usually grow slowly and painlessly with proptosis and downward displacement of the eye.

HH is 42-year-old man who presented with the complaint of some swelling of the right upper eyelid over several months. Examination by an ophthalmologist found vision in both eyes of 20/20 and mild temporal edema of the right upper lid. Exophthalmometry was performed with the OD measuring 21 mm and OS 19 mm. There was also found to be 4 mm of inferior displacement of the right eye. Palpation of the orbit found a firm mass in the area of the right lacrimal gland.

Echography demonstrated an encapsulated tumor of the right lacrimal gland on B-scan and medium reflectivity with a moderate angle kappa on A-scan (Fig. 221). Minimal spontaneous vascularity was noted. The differential diagnosis included a pleo-

morphic adenoma and a cavernous hemangioma, but the superotemporal location outside of the muscle cone was most consistent with a tumor of the lacrimal gland with the echographic features of a benign mixed tumor. CT scan demonstrated a mass in the superotemporal orbit with mild molding of the bone, but no bone destruction.

The patient was referred to an orbital surgeon for an en bloc excision of the tumor. Biopsy was not recommended because of the danger of violating the capsule with potential malignant recurrence of the lesion.

The lacrimal glands can be a source of globe displacement and lid swelling due to infection or nonspecific inflammation.

BS is a 23-year-old woman who complained of moderately severe pain around her left eye for 2 days. She had gone to a local emergency room and a CT scan was performed with no apparent abnormalities. She was sent home on pain pills and told to follow up with her eye doctor. She presented the next day to an ophthalmologist with worsening of the pain. Examination found vision in both eyes of 20/25 and a normal anterior segment by slit-lamp examination. Subtle s-shaped swelling of the left upper lid was noted and there was some tenderness to palpation in the superotemporal orbit.

Echography was performed and the right lacrimal gland measured 11.47 mm and the left measured 13.4 mm (Fig. 222). A-scan showed medium- to-high reflectivity bilaterally but there was a relatively low area centrally in the left gland. The diagnosis of a probable dacryoadenitis was made and she was started on a course of oral antibiotics with resolution of her symptoms in a few days. Repeat echography in 3 weeks demonstrated left lacrimal gland thickness of 12 mm.

Orbital pseudotumor, including that involving the lacrimal gland, is rare in children. Infectious or idiopathic dacryoadenitis is more common and is usually self-limited with mild symptoms of temporal upper lid swelling and tenderness. Echography provides a rapid and cost-effective method to evaluate the lacrimal gland in an office setting.

FIG. 222. Top: A-scan of lacrimal pseudotumor (vertical arrows). Bottom: Normal opposite gland (vertical arrows)

MS is a 4-year-old child with a history of progressive left upper lid swelling over several weeks. Examination of the eyes was unremarkable except for moderate nontender edema of the lid. The parents stated that the child had not complained of pain in that area at any time. A CT scan showed enlargement of the left lacrimal gland without apparent involvement of the orbital bone. The differential diagnosis included a solid tumor such as a pleomorphic adenoma, lymphoma, and pseudotumor. An oculoplastic surgeon was consulted and was concerned that the lack of pain and tenderness supported a solid tumor of the gland as compared to an inflammatory process.

Echography revealed an enlarged left lacrimal gland with low-to-medium and relatively regular internal reflectivity (Figs. 223 and 224). The findings were most consistent with an inflammatory process, such as pseudotumor, with malignant conditions, such as lymphoma, included in the differential.

The surgeon was very reluctant to perform an excisional biopsy of a possible pleomorphic

FIG. 223. A-scan of lacrimal gland (arrows)

FIG. 224. B-scan of gland (arrows)

adenoma because of the risk of converting the lesion to a more aggressive malignancy, but largely on the basis of the echographic findings the biopsy was performed. The pathology report stated that the final diagnosis was “chronic or smoldering pseudotumor of the lacrimal gland (dacryoadenitis).”

Another cause of globe malposition and lid swelling with orbital pain is orbital pseudotumor. Various series report the incidence of this inflammation to occur in 5% to 7% of orbital disease processes.39 Modern imaging techniques have allowed the subcategorization of orbital pseudotumor into the inflammation of specific orbital structures, such as the extraocular muscles. Acute pain made worse by moving the eye is suggestive of inflammatory myositis.

AC was a 21-year-old woman who lived in the Amana colonies in Iowa. She presented to the emergency room with the complaint of severe pain in her left eye starting the previous day. She stated that it was made worse on looking to the left and she also experienced double vision when she did this. Examination showed normal vision in both eyes with some swelling of the left eyelids with mild proptosis. The nasal conjunctiva showed moderate injection, especially over the insertion of the medial rectus muscle.

Only first-generation CT scans were available at that time and the patient was scanned with that modality. The radiologist reported “nonspecific left orbital fullness.” She was referred to the eye department for echographic evaluation. The right orbit

was normal and the left orbit revealed thickening of the medial rectus muscle and tendon on B-scan and low internal reflectivity on A-scan (Fig. 225).

The diagnosis of medial rectus myositis was made and she was started on high-dose prednisone with rapid improvement in her symptoms over several days. A complete systemic workup was performed to rule out an inflammatory process, such as collagen vascular disease, but all of the tests were normal.

Globe displacement with pain secondary to a neoplastic process is generally an ominous symptom suggestive of perineural infiltration by a malignancy. Such symptoms may be associated with adenocystic carcinoma. It is the most common malignant tumor of the lacrimal gland and pain occurs in up to 80% of these patients.

SC is a 27-year-old man who presented with complaints of an intermittent boring pain for several months around his left eye. Examination revealed fullness in the superotemporal orbit and some tenderness to palpation. Otherwise, the examination was unremarkable. A plain film x-ray was obtained and showed some evidence of erosion of the bone on that side. CT was performed and demonstrated a lacrimal mass with bone invasion.

Echography was performed and A-scan showed irregular internal reflectivity with a central low area (Fig. 226). Mild spontaneous vascularity was detected. The findings were consistent with a lacrimal gland malignancy with the differential diagnosis including adenocystic carcinoma. This was later confirmed on biopsy and orbital exenteration was advised.

Subtle displacement of the globe can be missed in the early stages even by experienced observers.

FIG. 226. A-scan of adenocystic carcinoma of lacrimal gland (vertical arrows)

EW was a 62-year-old engineer who noted difficulty in closing his left eye starting 4 months prior to presentation. Numerous specialists, including a neurologist, for the evaluation of an atypical Bell’s palsy, had seen him. He had undergone three MRI scans, two CT scans, two lumbar punctures, and numerous blood tests, including serology, to rule-out Lyme disease. He had recently noted a further reduction of vision in his left eye and had consulted with his local ophthalmologist, who diagnosed an inferior retinal detachment and referred him to a retinal specialist for surgery. The retinologist did not feel the retina was detached but suspected a choroidal detachment and referred him for echography.

Examination prior to the ultrasound found moderate lagophthalmos of the left eye and 2 mm of superior displacement of the globe. B-scan showed a 24-mm orbital mass indenting the eye inferiorly. A-scan revealed a very low reflective orbital lesion with a bone defect in the orbital floor with a maxillary sinus component to the lesion (Fig. 227). Because of these findings, the patient was asked about any skin lesions and he pointed out a lesion under his moustache that had lately been growing.

The echographic findings were suspicious for either a primary sinus carcinoma invading the orbit or perineural spread of a squamous cell carcinoma of the skin. The diagnosis of squamous cell was confirmed on orbital biopsy.

Another symptom of orbital disease associated with globe displacement is diplopia. The workup of this symptom starts with evaluation of the extraocular musculature and proceeds intracranially if a more proximate cause is not found.

FIG. 227. Top: B-scan of orbital lesion compressing globe (arrow). Bottom: A-scan of orbital component (small arrows) and sinus component (between second and third arrow)

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Most causes of diplopia originating in the orbit result from mechanical difficulties with the extraocular muscles, such as infiltration, compression, or entrapment. The most common entity causing muscle dysfunction in the orbit is Graves’ disease. Initially the muscles may show inflammatory changes and later can become fibrotic and noncontractile. They may not appear enlarged on imaging studies at this stage.

According to Gorman,40 the pathophysiology of Graves’ disease involves muscle swelling caused by

Case Study 125. Sinus Squamous Cell Carcinoma

the accumulation of inflammatory cells and water

binding glycosaminoglycans (GAGs) followed by subsequent muscle fibrosis. It is believed be an autoimmune disease where CD4 T lymphocytes become sensitized to an antigen common to thyroid and orbital tissue.41 The most common antibody in Graves’ patients binds with the thyrotropin receptor (TSH-R). There are two distinct subtypes of thyroid orbitopathy: congestive with retrobulbar deposits of GAGs and myopathic with impaired extraocular muscle function.

JN is a 16-year-old boy who presented with double vision on looking to the right for several weeks. Examination found vision in both eyes of 20/20 and mild proptosis of the left eye compared to the right. There was mild lid lag of the left eyelid. He was found to have 15 prism diopters of exotropia on right gaze. Forced duction testing was positive for restriction of adduction on the right. He had no history of diabetes or thyroid abnormalities.

Echography was performed and demonstrated thickening of the left lateral rectus muscle, which measured 5.2 mm compared to 3.8 mm for the right lateral rectus. A-scan demonstrated irregular internal reflectivity (Fig. 228). Thyroid function testing was normal and the clinical findings were atypical for Graves’ disease with abnormality of only the lateral rectus muscle.

Because he was orthotropic in primary gaze, it was elected to observe him and repeat an examination in 3 months. At that time his clinical findings were unchanged but repeat echography showed thickening of several other extraocular

FIG. 228. A-scan of lateral rectus muscle in Graves’ disease (vertical arrows)

muscles bilaterally, which supported the diagnosis of Graves’ disease.

Other infiltrative processes of the extraocular muscles include malignant processes such as lymphoma and metastatic tumor.